1528053717 NPI number — WILLIAM J LIPHAM M.D.

Table of content: WILLIAM J LIPHAM M.D. (NPI 1528053717)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528053717 NPI number — WILLIAM J LIPHAM M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LIPHAM
Provider First Name:
WILLIAM
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528053717
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9801 DUPONT AVE S
Provider Second Line Business Mailing Address:
SUITE 425
Provider Business Mailing Address City Name:
BLOOMINGTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55431-3100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
952-567-6092
Provider Business Mailing Address Fax Number:
952-567-6176

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9801 DUPONT AVE S
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
BLOOMINGTON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55431-3100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-888-5800
Provider Business Practice Location Address Fax Number:
952-884-2656
Provider Enumeration Date:
09/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  41668 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207WX0200X , with the licence number: 41668 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 34027700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 668057700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com